Mosher, Norman K. Pine View Cemetery 8, Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Ef MHt OK _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: . -7IZI x 11667
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAMe: ._—_y_1 LY_ ry^CVn'. __/n,cgsea /II 842 _
TYPE OF CONTAINER:}L� 44+'I ry wF- r( /W^Nj
PLACE OF DEATH: _ ' I FUIVr � V,IRjc FJ 1711j
ESTIMATED WEIGHT OF REMAINS IS CONTAINER_ )� LLr
PLACED IN HOLD:
PLACED IN REFRIGERATION: Z;X /1I
DATE OF CREMATION: py� ])$I 'l 1b
jOrn F.�
TIME STARTED: -I. TIME COMPLETED:
1 �O.3S(I1�
PLACED IN RETORT: '40#_MOVED: g:m ATI T tq'lll i 1;yM}'I
„ I
RETORT pIN WXICH REMAINS WERE CREMATED: Qih4.R11'S
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN /8 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL REF RETAINED IN THE PERMANENT FILED THE HE CREMATORY.
S///���111 OeWrlor, MMS UM
EW RK Division of pNI51pImOFCE,. ,ET;RIM
°""'YOND` Cemeteries n
alapwrre'.ISBiP6336
Authorization for Cremation and Disposition
This ANbotlaaskn Form must be completed and signed prof to ENlrery M remains for
3cm eon.
Dale: m OR r16OC Number o or 3
Crematory Name Pmawew CmwwgrlMl
Address: 31 QuaMr Rwd, Olmmsbury, NY 128M pM1e, 15101TLS4ei]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried cN b)Uabma me remains of the debasement and Two cadaasa-I sing nw remaim Into a Gemedon Proof Mere
they us suldiectedkIntense Mat and flame. The heat and flame will Inclrranb and wrwume eve ing except bone and r 1.
MkhamallMAMilbeleaab cnma8on.
Fcimng mma400, the crematory all take resonate,etlon5 to remove all Ofine remains arm other material from the cremation
chamber bin same minimal dust and residue wll LNely be left behind. The crematory will someone lncldendl and krelgn materiel man
the remains add he incidental and kreign material will be dimmed of as repulred by lax. The Mmmed remains will M frechandelly
WNenZed lino small Nieces and Needed into a designated consumer or um. Cm rellalns genmalry am WleerhM unth no
eingm bagmen)4 mwgnhabM u a lk lNanue.
OMNINGOFTNECMTAMER
The uemalory may only qHn the Wmeina holding the unumemekd human remain$ In limited ti measurements such Ad W confirm this
ideory of he delta or M ensure memo material Is macsed Mkh night Iryure employees or damage tlN tlemelay aOWnY N
human MINIM an dellvmad In a mn ner which Is not suitable ter cumNpn such as wnmonlal Or Mt lWeb1.Sra
inanely will require Mm the melons tea moved Into a eau Kabee wool Mr before ttaccepis She nmalne. The morning Ora
container orlon banfier ev removed of remak9)till M cinducted boom a wMem and will M done In of Cy.WM dignity BM maw
OENTIFICATION OF DECEASED
Name W Lbw Norman K Mmtw MNiW SOWS: OFmrtM
Last Know Address: M FUIW Rpd,C ,NY 1211
Ni M Cestk 30 FWIa Rood. CwirM NY 12043 II
so-: ON OF Age: 80 DOE, L3rzfl iw Dao Moam:07l162ma Esamak "M fix+ De,
DmmpAn W caSkNCOhtaharin Mich remains or ce delivered.
(rypmffieri MetimenufNrer) MaeKws Auma Wwd and CaMMM Cremation CmtaMr
PSRSMN CONTROL OFOB Off ON
(Fersw(sl in ttnbol0ldrepvtm, - Ne DNEddmldlpwingl
aMh'a are Rre MsignatM agmi ofine dxe6s tl desgneled In a will awltlen IluWmenl exacoed pursuarli W Fubllc
Hwam Lax smlm 42W.
0
Me have re,knowledge lost the de sed execNetl a woman instrument ResonantW PUNk Health law sMlm 4201 or
4wilROmmining mrectons fame d'R(CSNona his 0r her remains add Ions are the assai(s) Mang on"under Pi HveM Law
Symoa201 and navamerig111WaNwr¢e uemaeon of me remYrgMich aewaeM. Wy rMabonemp W1Mdmwu i$S$
follows.
Nmren K. W r
DOSaeSSf(Rev. =15) Page 1 of
Authorization for Cremation and Disposilion
rrnsent from the her cerowl
Numbr, 3 Descrlp0on:My suMuss;calla egNteen years of said a Near
i. A pnacn diversified in writing pU aS to Pudk Heats Low S tvi 4201(3):
2. The surviving epwse.
3. The survival dementic pwtner',
3. My surviving hold NgMeen yeeR M age or count
<. Asurvrving Potent.
S. A surviving erring eighteen years OF Or Older,
6. A IaMWly agpOirBed guaaian:
T. Piry prmonad ligMeen years of age or Order Bn@kd O share In be estlle and and iaWre Coal In Rletionsnip to The deceased'.
& AMMap(cRed fiduciary Of the estate:
9. A dMB Mend or relelNe who has exerted a mO s� ment pursuant W PUdk He h Use Seeri0n 0!01(1).
10. AIfaced Never of a coundy or a PUNIC admnesttl ae{anfe] WnuarM1 to Me frurtagate a Court Pmced use Ms..
fail May either person vitro is acing On WFdlf of the decreased Card verve Nor xm w a artery sfe4ment purl W Public HeeM
W/sxWn 4Qo1(7).
ALL 714F£E Of the/dbxlrgl
iUll INJe Mretry amain Nat 0e GMy 0Me axes^S aces nM¢ndM a Mtlery, Call parce. power call. ratlmeNve implam,
OrradWdG dew and Nafany mi naviali read removed undramatic eseecturrom of Vas AUModaatian Furl. Fellunbremmre
Xrow Min Mono asm n may muX In Mrm Wtlw cm Mq and cm Mry graonnel.
INle arm IInsf izns have Lean giren W R I rem
reg:Wing NB removal a any pewnal MPo or NMr thing of value welch a ny perecn arguing WI want'remiy member of be
decided vil W preserve. PIRUYew acnaWnum
is not reespondiue fa Me remouai ofpereon M m m al"I in e ntanwr or from theremains of the deceased. Personal Mmt lBR in the
ooaalner or with Me remains"I M destroyed by MB wamaron precess and cannot he mdeved after Chem anon.
_IIWe hBrepy auMorYe Pineu'An'Cmmatmum �
W cm m Me mnalm M MedxewM.
FINALp9P09RfON
The pnxO eWw W reserve Me cremalM remai ns 0 Me dma n Me oa IS
Name Remrf I. OmarMe
Mdrm TSherman Avel Corinth, NY THIN p�. 1518)86a-92C5
TM NdmaM remaMs OF deceased will be attended as 1011ONS
ke 1 ,wK I, 4: 1- d , yt�
If v art fresh de Po named above does May Older possession Of and cremates Mariana.
Plr mCMm hm is addat W gM pvmefMid
Me remains W Demander Fuaml H . led,
nee+rm.aaw byml'mry
in Person or by vM dvW mat
Namur K "W
0OS1B56f(Rev. W15) mwwr� Pai
Authorization for Cremation and Disposition
�n�gn me rmrorrogl
O memo undeRrnM Met d me Somali am not oatmeal xvlNn 1M tWS of gtlM1YlT.
Pmavle.cremarorium in"mepwe ameremeing in
ftessiames,,sil
an immovable manner, such as by scatenng
CREMATION COmAINERNRN
(Inl ONEdma Scattering)M um to Ea Wetl as a consumer be Me aemams mmYreIle been W,mIM IMM Cenemom Fuji Moor. IM
and is desmeen as Wilson: LAIN M 3,
NYa understand Mtl if Na was is Im Small b Wd V9 MEm PemamE normal,AA abotioral had common may M uM]Md4Mry
OR-
M um iaM YSl WnflnaM. IM4wMmarer4tllalrtm un'a pudwM a Wnuw gwYMd
Reforms,Grommacrum So gece Me strongest someone in
pr.ao.rwm
a dgN Summary container M MNery.
This AssenwmMion Form Was gWldel by RdRllf DMBmue Bona ended at
p ow wN
Densmore Fune,N Name, Inc
Sherman Avenue Corms, NY 128R3 Rusv
ends sgned by the hurearal dlxWr as Meese to m eaestar s,
iWe moo rttcvM a competed xPy of this A nyhommolon Form.
The peMnni IdMUM BNoe lalam W powers) In tonbol or dbpsymbon.Mro by signing M4AUMosent Form,a1 s)
to the accowy and wmplM m or Me Infamntol cOltltned In MM Agglomeration Form hang aggMpmm MMa ronegmng.
shorn MIS 18M Myth July an 20
Susan D. She nni4
sense
roymyr m,mi w.e
Rota)L 0ermmum
1Cg10���
Norman K. Mahe
�W®n
OOSteflIff(Rev. MIS) PpsS W 3